Saturday, October 17, 2009

The Price of Safety: Part II, Recent derailments expose problems

This is the second portion of a series about safety within Metrorail. The Price of Safety is an ongoing feature at Greater Greater Washington.

Previously, we looked at a rash of accidents involving Metro track workers. A common theme across many of those incidents was a problem with the implementation of safety rules within Metro.

In some cases, had rules been followed, the accidents would not have occurred. In other instances, implementation of NTSB recommendations might have averted tragedy. A similar theme emerges upon a close examination of Metro's recent history of derailments. For the purposes of this post, we will focus on the past 6 years of derailments. The fatal 1982 Orange Line derailment will be addressed in a later installment.

Since 2003, Metro has experienced a significant number of derailments. Many of these incidents involved out-of-service trains in rail yards, or on segments of pocket tracks. There are several notable incidents in recent history that have involved in-service trains, including one that resulted in passenger injuries. The causes of these derailments vary, though one factor remains the same--a failure to implement safety improvements throughout the system.

On January 20, 2003 the last car of a Blue Line train derailed along the elevated track outside of the National Airport station. Forty-six passengers were safety evacuated on that frigid night, though the damage totaled over $100,000. Over the next five years, there would be at least nine more derailments. In June of 2005, amid the rash of derailments, the Washington Post published an investigative piece entitled "Safety Warnings Often Ignored at Metro." The feature piece pours over internal Metro documents, as well as accident reports, and comes to some startling conclusions. Many of these were eerily prescient. After the National Airport crash, an internal investigation determined that employees were aware of the potential for problems. Documents showed that track managers expressed concerns relating to the type and condition of the track being used at the location. According to interviews, those concerns were passed up the chain to upper management, though no action was taken.

Warnings about other causes of derailments, such as a lack of track lubrication were also ignored. Investigators determined a lack of lubrication caused a derailment at the Alexandria rail yard. There was a brief push towards getting track properly lubricated, but over time the efforts began to falter. Don Painter, former manager of the track department, told the Post that he blamed a lack of institutional memory. "The superintendent retired, the assistant superintendent went to a different location, the maintenance manager went somewhere else, and the guys, when no one told them they needed to keep lubricating, the ball got dropped."

It took a year and several derailments later for Metro to implement directives regarding track lubrication.

Metro's track department was rife with systemic problems, especially concerning track inspections. The Post's investigation turned up a 2004 audit that showed some track workers did not know how to report problems to their superiors, and that inspectors often overlooked problems because they were required to cover an unrealistic amount of track each day. Additionally, prior to 1999 there was no official training program for track walkers, and audits showed that even after programs were implemented there was a lack of proper training.

In 2005, Susan Coughlin, a former NTSB member, noted that these incidents were "indicative of systematic oversight problems which, if left unaddressed, could produce a catastrophic accident."

Nearly four years after the Blue Line derailment, and 18 months after the Post article, a Green Line train derailed outside of the Mt. Vernon Square station. At 3:45 pm on January 7, 2007, the fifth car of the six-car train derailed, injuring 23 people. The NTSB determined that a problem with wheel maintenance caused the derailment. In the Railroad Accident Report, the NTSB also identified systemic problems within Metrorail. From the the report, RAR-07-03,

WMATA was aware of the wheel climb derailment problem with the 5000-series cars before this accident. Transit industry research and discussions with WMATA management indicate WMATA was aware of work done by the Transportation Research Board for the National Academy of Science and National Academy of Engineering on flange climb derailments in transit operations. Additionally, WMATA commissioned, participated in, and received the final Wheel-Rail Interface Study from the TTCI. Extensive testing to determine the cause of these relatively similar derailments in the 5000-series cars failed to produce a solid answer. Also, the APTA panel concluded that there was no single cause in the seven derailments it examined; however, the panel did identify several specific factors and made recommendations for WMATA to consider to prevent future derailments. Nonetheless, after requesting reviews by industry experts and funding related research work, WMATA failed to effectively address the proposed safety recommendations before this accident. The Safety Board therefore believes that WMATA should establish a process, including a single point of responsibility, to prompt timely evaluation and action on proposed safety improvements that are identified as a result of accident and derailment investigations and related research projects.

In June 2008, an Orange Line train derailed outside of the Courthouse Metro station. There were no injuries, but over 400 passengers needed to be rescued from the tunnel. Significant damage was done to the track in the area. Interestingly, the train operator did not immediately realize the derailment had occurred. A Metro supervisor happened to be riding on the train, felt a jolt, and alerted the train operator. The train had traveled more than 2,300 feet with the front wheels of the third car off the track.

An internal Metro investigation determined that a track walker had failed to report a significant problem with the track in the area. From a WMATA statement:

"Our inspector failed to recognize the out-of-tolerance rail conditions," according to Metro's Chief Safety Officer Ronald Keele. "The track conditions compounded with the forces of the moving train caused one wheel to climb atop one track and the other wheel to drop to the ground. We are very fortunate that there were no injuries."

The findings of Metro's internal investigation determined that the track inspector failed to detect "defects in the track's geometry" in the area of the derailment and "violated several inspection procedures," according to Keele.

The inspector did not inform the Operations Control Center of dangerous track conditions, did not report any dangerous or defective conditions to his supervisor, and failed to properly measure the space between the two tracks.

The inspector was suspended for five days as it was his first offense. Again, Metro stated they would work to revamp their training for track inspectors.

Metro's safety record regarding derailments highlights significant organizational deficiencies. Time and again, there was prior warning that problems could develop. Time and again, these warnings went unheeded. The same pattern emerges when looking at prior collisions and "near-misses" on Metro. Again, we see warnings from both within Metro and the NTSB that were ignored. It was no secret that trouble was brewing.

by Dave Stroup, filed under Features at 11:25PM   0 

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Sunday, October 11, 2009

The Price of Safety: Part I, Track Workers Face Dangers

This is the first portion of a series about safety within Metrorail. The Price of Safety is an ongoing feature at Greater Greater Washington.

Metro employees who inspect and maintain the system's infrastructure are vital to safe and reliable operations. The training, morale, and by extension safety of these workers must be an top priority. Sadly, Metro has suffered the loss of several track workers in recent years.

In 2006, Metro lost three track workers in two separate accidents. On May 14, 2006 senior mechanic John Lee Wong, 49, was struck and killed by a Red Line train near the Dupont Circle station. Six months later, on November 30, 2006, Leslie Cherry, 52, and Matthew Brooks, 36, were struck near the Eisenhower Avenue station. Both would die from their injuries. The National Transportation Safety Board investigated the incidents, and at the time had some strong words for Metro. Then NTSB Chairman Mark Rosenker called Metro's worker safety record "unacceptable" and oversaw a detailed reconstruction of the incidents. For comparison, during the five year period (2003-2008), there were 10 track workers killed nationwide. Three of them were Metro workers. That figure encompasses all forms of heavy rail.

In January 2008, the NTSB completed their accident reports. The two Railroad Accident Briefs, RAB-08-01 and RAB-08-02, show the NTSB's findings and probable causes for the accidents. For the Dupont Circle incident, the NTSB concluded that Wong was either unaware of the presence of the train, or was unable to identify and reach a safe area away from the train's path. Furthermore, the NTSB identified weaknesses in Metro's right-of-way rules. The NTSB found that both track workers and train operators lacked vital information about each other's presence. This resulted in a train operator that was unaware of the presence of wayside workers and a lack of properly reduced train speed through the work area. The report also noted a lack of rule compliance, testing, and enforcement within Metrorail. Similar institutional causes were cited for the Eisenhower Avenue accident, and in that case the train operator also failed to slow or stop the train until after she had struck the workers.

The NTSB issued multiple recommendations to Metro to ensure enhanced track worker safety. These included:

• Establishing procedures to be used for members of a work crew to acknowledge a lookout's warning that a train is approaching on a particular track from a particular direction before a lookout gives an all clear signal to a train. (R-08-01)
• Establish a systematic program for frequent unannounced checks of employee compliance with Metrorail operating and safety rules and procedures. (R-08-02)
• Perform periodic hazard analyses on the deficiencies identified by unannounced checks of employee compliance in response to Safety Recommendation R-08-02, and use the results to revise Metrorail training curricula or enforcement activities, as necessary, to improve employee compliance with operating and safety rules and procedures. (R-08-03)
• Promptly implement appropriate technology that will automatically alert wayside workers of approaching trains and will automatically alert train operators when approaching areas with workers on or near the tracks. (R-08-04)

At the time of these recommendations, NTSB member (and now Chairwoman) Deborah Hersman felt that Metro did not have a strong culture of safety. Hersman was quoted, "a strong safety culture doesn't take dollars; it takes a will. They had rules. Those rules weren't observed."

In the wake of the NTSB findings, Metro general manager John Catoe vowed to make the transit system the safest in the country. Catoe said Metro would look at adding new technology to improve the safety of track workers. Polly Hanson, the Metro safety and security "czar" at the time, said she hoped to implement the NTSB's recommendations for alert equipment. Anonymous sources told the Washington Post that staff within the rail department were not in favor of this due to the extra work it would require.

Around this time, Metro hired a new Chief Safety Officer. Ronald Keele was brought on as part of Catoe's safety reform efforts. Keele had previously served in a similar role at Metro, and then at MTA in Maryland. He was also chief safety officer for NASA's space shuttle program, in the time period prior to the Columbia accident. Keele said one of his top priorities would be improving safety for track workers.

In July 2008, Catoe attended a Federal Transit Administration Safety Summit. From a U.S. Department of Transportation newsletter:

Mr. Catoe raised the following issues such as recognizing gradual changes to operating conditions, getting "out in front" of safety problems publicly, and leadership acceptance of responsibility and commitment to solving and tracking problems. Mr. Catoe emphasized the importance of top-down leadership and accountability, and direct communication with employees. He also shared the importance of rules enforcement programs and agency-wide participation.

In the nearly two years since the new safety chief was hired and the NTSB reports were issued, it's unclear how much progress has been made. According to WMATA's web site, Alexa Dupigny-Samuels now holds the position of Chief Safety Officer. Dupigny-Samuels was appointed in February 2009. The press release announcing Dupigny-Samuel's appointment offers no information about Keele's future. Metro has not answered inquiries about Keele's departure or reassignment. The latest update regarding the track worker protection technology was that Metro was still considering the options.

Tragedy would again strike Metro track workers this year. On August 9, Mike Nash, 63, was struck and killed by a gravel-spreading machine on the Orange Line. Nash had been working on the rails for 19 years. The NTSB declined to investigate that incident, as it did not involve a train, but rather maintenance equipment. On September 10, John Moore, 44, was struck by a train between the Braddock Road and National Airport stations. He died four days later. The NTSB was notified of the incident. At this time, Metro has offered little information about the incident. Moore worked with communications equipment, but it is unclear what work he was doing at the time of the accident.

It remains to be seen the cause of Moore's death, and whether it is directly related to any of the problems identified by the NTSB in 2006. With regard to the 2009 deaths, Catoe says that Metro has "got to get back to the basics of safety." Operating a railroad is dangerous, and there will be accidents, this much is for sure. However, given the seriousness of the NTSB recommendations issued not even two years ago, it is important to evaluate whether Metro has improved. Has Metro been able to develop the culture of safety Hersman deemed so important? Has the turnover in the safety department hampered these efforts? Has John Catoe lived up to his words of getting "out in front" of problems? The answer to these questions become clearer after looking at all of the areas of Metro safety.

by Dave Stroup, filed under Features at 3:07PM   0 

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The Story Behind Alice Swanson's Ghost Bike

In August 2009, a strangely compelling story unfolded in the District. On August 28, the District Department of Public Works removed a "ghost bike" memorial from the intersection of Connecticut and R Streets, NW. The bike had been placed in the memory of Alice Swanson, a bicyclist who was struck and killed by a trash truck in July 2008. The bicycle, a silent reminder of the dangers cyclists face, had remained in place and maintained by Swanson's family and the Washington Area Bicyclist Association. The removal of the bike sparked an outrage in the cycling community, and eventually garnered coverage by local television networks and local web sites. Many questions remained about how and why the bicycle was removed. On September 28, I published the following report.

On Wednesday August 19, Ed Grandis, the Executive Director of the Dupont Circle Merchants and Professionals Association (DC MAP) sent an email to Mark Bjorge at the District Department of Transportation. In this email, Grandis characterized the ghost bike as being in "significant disrepair" an "eye sore" that was "not a memorial." Grandis requested the removal of the bike on behalf of "several commercial property owners." Also copied on this email was DC MAP's board, including Susan Taylor (Church of Scientology), David Perruzza (JR's Bar and Grill), Jonathan J. ten Hoopen (Black Fox Lounge) and James McGlade (The Leather Rack). When asked via email, Grandis declined to comment for this story. Perruzza responded writing "I work on 17th street but from what I understand they removed it because it is in the way of pedestrian traffic."

On Thursday August 27, Andrew Huff, Mayor Fenty's Ward 2 Outreach Specialist sent an urgent request to DPW asking that the lock on the ghost bike be cut immediately. The email was sent at 7:33 PM and asked that the lock be cut before close of business on Friday. Huff said that it was "a Mayoral request and your assistance is greatly appreciated." The request did contain a note saying "DO NOT REMOVE OR THROW BICYCLE AWAY - JUST CUT THE LOCK AND LEAVE AT LOCATION. FAMILY MEMBERS WILL RETRIEVE BICYCLE TOMORROW."

At 8:20 PM, Jim Sebastian, who works on bicycle matters at DDOT, replied to Huff and DPW saying that Eric Gilliland at the Washington Area Bicyclist Association had located the key to the lock, and asked if the bike's removal could wait until Monday. Huff replied saying "[w]e can wait until Monday but not later." Huff the notified DPW that their services would not be needed.

On Friday, August 28, Earl Simpson at DPW reported that they had cut the lock on the bike. He told Anthony Duckett, Associate Administrator in DPW's Solid Waste Management Administration that the bicycle had been left at Cosi, "because we didn't want anyone to take it while its unlock (sic)."

On Monday, when the media began asking questions about the ghost bike's removal, there was much discussion within DPW, the Executive Office of the Mayor (EOM), and DDOT on how to respond. According to Nancee Lyons at DPW, the bicycle was removed via the abandoned bicycle policy, and not the sidewalk memorial policy. Had it been removed under the memorial policy, a 30-day notice would have been left. The public affairs campaign regarding the incident began to get muddled, as it was unclear whether the Mayor's Office or DPW would take the lead in responding.

I had asked DPW for an official comment on Monday, and internal communication between DPW and EOM revealed a bit of conflict. Mafara Hobson, Fenty's Director of Communications was unwilling to take the lead wanting "to leave the Mayor's name out of the matter." DPW tossed around the idea of sending me a comment explaining the bike's lock had been cut and it had been left in a secure location to prevent theft. I didn't receive an official comment until Tuesday, September 1. This email referenced only the 30-day policy, and extended condolences to Swanson's family. It was unsigned and provided no further information.

The most interesting part of the internal discussion was the consideration of an official memorial being placed for Alice Swanson. Sarah Latterner at the Mayor's Office arranged to call a meeting with all of the involved agencies, as well as WABA and Swanson's family. Francisco Fimbres at the Mayor's Office asked DDOT to "come prepared to suggest a memorial on the sidewalk. Be it a tree box structure with a bike and flowers + a little placard. WABA or family can pay, DDOT and EOM could support and help them make it happen."

Lyons, in an email to DPW Director Bill Howland, said "so now that the Mayor's office apparently asked for this to be removed, folks are apparently freaking out at the reaction. I don't think affixing a permanent memorial is the right way to go to appease just one family, do you?"

Monday afternoon Howland sent an email to City Administrator Neil Albert, Fenty's Chief of Staff Carrie Kohns, Hobson and DDOT Director Gabe Klein saying he was opposed to any permanent memorial to Alice Swanson. Albert and Hobson would agree, and the official public relations response would be to say that the official policy was that memorials are removed after 30 days and that the city is sorry for the family's loss. That would be the end of discussion on the matter.

What remains unknown is why this issue became such an urgent priority to the Mayor's office. DC MAP's request did not indicate there was an urgent need to remove the bicycle. These emails were obtained under the Freedom of Information Act, however it does appear that Mayor Fenty's office withheld many documents. I sent separate FOIA requests to both DPW and EOM. DPW's response includes over 80 pages of emails, many that were sent from staff in Fenty's office. Many of those emails were NOT also included in the FOIA documents supplied by the Mayor's Office. I was provided with no documents that show how the matter moved from DDOT to EOM and why it became a priority. Also, there is still no information on what businesses approached DC MAP with the original request. This would not have been covered by the FOIA request.

If anything, this whole incident has revealed some tension and blame-passing between DPW and Fenty's office. Fenty's office demanded the prompt removal of the bike, and then essentially hung DPW out to dry. It's no surprise I received 80 pages of documentation from DPW and roughly 4 pages from Fenty's office. They fall back on the "30 day policy," however the memorial clearly remained for more than 30 days. DPW's communications indicate the bike wasn't removed under the 30 day policy, but rather under the abandoned bicycle policy.

Personally, I believe that the replacement memorial idea should not have been shot down so quickly. Had the city offered to help dedicate a treebox near the site, I don't believe the 22 ghost bike art project would have happened. Rather we would have had a small, unobtrusive memorial. From a political standpoint that would have been much better than the mess that unfolded. It would not have necessarily resulted in a "Pandora's Box" as the DPW chief called it. Clearly this memorial was allowed to remain beyond 30 days, so this was done on a case-by-case basis. Permanent memorials for tragedies in the future could also have been handled on a case-by-case basis. Having some plaques on some treeboxes is not unheard of, and would not clutter up the city. by Dave Stroup, filed under Features at 3:48PM   1 

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